Provider Demographics
NPI:1750128906
Name:BOLOGNA, CORIEN (LCAT, ATR-BC)
Entity type:Individual
Prefix:MRS
First Name:CORIEN
Middle Name:
Last Name:BOLOGNA
Suffix:
Gender:F
Credentials:LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PARKRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3418
Mailing Address - Country:US
Mailing Address - Phone:631-682-9507
Mailing Address - Fax:
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2250
Practice Address - Country:US
Practice Address - Phone:631-682-9507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2936702101YS0200X
NY001744-01221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool